Medical Care

Most patients (>75%) require only symptomatic therapy with NSAIDs. Approximately 10% of patients need treatment for extrapulmonary disease, while 15% of patients require treatment for persistent pulmonary disease.

Steroid treatment

Corticosteroids are the mainstay of therapy.

Generally, prednisone given daily and then tapered over a 6-month course is adequate for pulmonary disease. Earlier recommendations suggested an initial dose of 1 mg/kg/d of prednisone; however, more recent expert opinions endorse a lower dose (eg, 40 mg/d), which is tapered to every-other-day long-term therapy over several weeks. In one study, treatment of acute exacerbations of pulmonary sarcoidosis with steroid doses as low as 20 mg of prednisone for a median of 21 days improved spirometry back to baseline and improved clinical symptoms.
[56] Most patients who require long-term steroids can be treated using 10-15 mg of prednisone every other day.

Some data suggest that corticosteroid use may be associated with increased relapse rates. However, data suggest early treatment of stage II sarcoidosis with oral prednisolone for 3 months followed by inhaled budesonide for 15 months improves 5-year pulmonary function and reduces the need for future steroid treatment.
[57]

High-dose inhaled corticosteroids may be an option, but conclusive data are lacking. Inhaled corticosteroids, in particular, can be used in patients with endobronchial disease.

Although corticosteroids are used for symptom relief and remain the mainstay of therapy, their efficacy in this disease is unclear. Since many patients' conditions improve spontaneously, showing a true benefit to therapy requires a careful control arm.

The best study addressing corticosteroids was the recently completed multicenter trial from Britain sponsored by the British Thoracic Society. In this nonrandomized study, 55 patients were selectively observed or treated with corticosteroids. Additionally, patients who were thought to have an immediate indication for steroids were treated. The trial required a 6-month run-in period to exclude patients who improved spontaneously. At the end of the trial, the groups treated with long-term steroids fared better on some measures than did the patients who were observed and treated with short bursts of steroids (see Table 1 below for detail).

Acthar gel (repository corticotropin injection) was used to treat pulmonary sarcoidosis in the 1950s. It was abandoned because of cost and toxicity compared with prednisone. More recently, it has been suggested as an alternative in patients who are on high-dose prednisone.
[58]

Nonsteroid treatment

Noncorticosteroid agents are being increasingly tried. Common indications for the initiation of such agents include steroid-resistant disease, intolerable adverse effects, or patient desire not to take corticosteroids.

Methotrexate (MTX) has been a successful alternative to prednisone and is a steroid-sparing agent.
[59]

Chloroquine and hydroxychloroquine are antimalarial drugs with immunomodulating properties, which have been used for cutaneous lesions, hypercalcemia, neurological sarcoidosis, and bone lesions. Chloroquine has also been shown to be efficacious for the treatment and maintenance of chronic pulmonary sarcoidosis.
[3, 4]

Cyclophosphamide has been rarely used with modest success as a steroid-sparing treatment in patients with refractory sarcoidosis.
[5, 6]

Azathioprine is another second-line therapy, which is best used as a steroid-sparing agent rather than as a single-drug treatment for sarcoidosis.
[7]

Chlorambucil is an alkylating agent that may be beneficial in patients with progressive disease unresponsive to corticosteroids.
[8]

Cyclosporine is a fungal cyclic polypeptide with lymphocyte-suppressive properties and may be of limited benefit in skin sarcoidosis or in progressive sarcoidosis resistant to conventional therapy.
[9]

Infliximab
[10, 11] and thalidomide
[12, 13] have also been used for refractory sarcoidosis, particularly for cutaneous disease. Infliximab appears to be an effective treatment for patients with systemic manifestations such as lupus pernio, uveitis, hepatic sarcoidosis, and neurosarcoidosis.

In addition, long-term treatment with infliximab can be effective for extrapulmonary sarcoidosis, according to a retrospective study of 26 patients with biopsy-proven sarcoidosis.
[14] In the study, sustained resolution or improvement occurred in 58.5% of organs, but disease activity progressed in 5.7% despite treatment. In 57.7% of patients, there were adverse events during an average duration of therapy of 46.2 months.
[14] Improvement in pulmonary imaging findings was observed in patients with pulmonary sarcoid after initiation of infliximab treatment, but results at post-treatment were inconclusive. Infliximab treatment was well tolerated.
[14]

Nontreatment and other issues

For pulmonary disease, asymptomatic pulmonary function testing and/or chest radiography abnormalities are not an indication for treatment. In patients with minimal symptoms, serial reevaluation is prudent. Significant respiratory symptoms associated with pulmonary function test and chest radiograph abnormalities likely require therapy. For such patients, treatment is indicated if objective evidence of recent deterioration in lung function exists. As mentioned above, corticosteroids can result in improvements in the functional vital capacity and in the radiographic appearance in patients with more severe stage II and III disease.

One study demonstrated an approach that may minimize the use of corticosteroids without harming the patient. This is accomplished by withholding therapy unless the patient shows at least a 15% decline in one spirometric measure associated with increasing symptoms or, if asymptomatic, withholding therapy unless the patient shows worsening pulmonary function test results and a change in the chest radiograph.

Surgical Care

Lung transplantation is a viable option for patients with stage IV sarcoidosis. Transplantation in such patients should be strongly considered when the forced vital capacity falls below 50% predicted and/or the forced expiratory volume in 1 second falls below 40% predicted.
[15] Patients with advanced sarcoidosis awaiting lung transplantation have a high mortality rate with a median survival of less than 2 years. Mortality is most closely linked to elevated right atrial pressure. In one retrospective cohort study, survival after transplantation determined by the Kaplan-Meier method was 62% at both 1 and 2 years, and a mere 50% at 3 years.
[63]